Emily E. Haroz

Cultural concepts of distress and psychiatric disorders: literature review and research recommendations for global mental health epidemiology

BACKGROUND Burgeoning global mental health endeavors have renewed debates about cultural applicability of psychiatric categories. This studys goal is to review strengths and limitations of literature comparing psychiatric categories with cultural concepts of distress (CCD) such as cultural syndromes, culture-bound syndromes, and idioms of distress. METHODS The Systematic Assessment of Quality in Observational Research (SAQOR) was adapted based on cultural psychiatry principles to develop a Cultural Psychiatry Epidemiology version (SAQOR-CPE), which was used to rate quality of quantitative studies comparing CCD and psychiatric categories. A meta-analysis was performed for each psychiatric category. RESULTS Forty-five studies met inclusion criteria, with 18 782 unique participants. Primary objectives of the studies included comparing CCD and psychiatric disorders (51%), assessing risk factors for CCD (18%) and instrument validation (16%). Only 27% of studies met SAQOR-CPE criteria for medium quality, with the remainder low or very low quality. Only 29% of studies employed representative samples, 53% used validated outcome measures, 44% included function assessments and 44% controlled for confounding. Meta-analyses for anxiety, depression, PTSD and somatization revealed high heterogeneity (I(2) > 75%). Only general psychological distress had low heterogeneity (I(2) = 8%) with a summary effect odds ratio of 5.39 (95% CI 4.71-6.17). Associations between CCD and psychiatric disorders were influenced by methodological issues, such as validation designs (β = 16.27, 95%CI 12.75-19.79) and use of CCD multi-item checklists (β = 6.10, 95%CI 1.89-10.31). Higher quality studies demonstrated weaker associations of CCD and psychiatric disorders. CONCLUSIONS Cultural concepts of distress are not inherently unamenable to epidemiological study. However, poor study quality impedes conceptual advancement and service application. With improved study design and reporting using guidelines such as the SAQOR-CPE, CCD research can enhance detection of mental health problems, reduce cultural biases in diagnostic criteria and increase cultural salience of intervention trial outcomes.

Psychometric evaluation of a self-report scale to measure adolescent depression: The CESDR-10 in two national adolescent samples in the United States

BACKGROUND There is a need for brief instruments to screen for depression in adolescents that are valid, reliable and freely available. The aim of this study was to investigate the psychometric properties of a 10-item version of the CESD-R (CESDR-10) in two national adolescent samples. METHODS Sample 1 consisted of N=3777 youths (mean age 15.7) and Sample 2 contained N=1150 adolescents (mean age 14.5). We performed confirmatory factor analysis, evaluated construct validity, examined differential item functioning, and assessed internal consistency reliability (α). RESULTS The results suggest generally strong psychometric properties for the CESDR-10. The CFA 1-factor model showed good model fit. Construct validity was partially supported in Sample 1 and mostly supported for Sample 2 based upon the characteristics examined. The CESDR-10 showed configural and metric invariance across both samples and full measurement invariance across sex. There were no notable differences in discrimination parameters or clinically significant differential item functioning between samples or sexes. LIMITATIONS Criterion related validity was not assessed in this study. Further studies should evaluate the scale in comparison to a psychiatric diagnosis. In addition, this study utilized a web-based format of administration which may influence participants׳ answers. In future studies, the CESDR-10 should be administered in other settings to more thoroughly establish its generalizability. CONCLUSION In clinical and non-clinical settings alike, time pressures make the availability of brief but valid screening measures critical. Findings support future use of the CESDR-10.

How is depression experienced around the world? A systematic review of qualitative literature

To date global research on depression has used assessment tools based on research and clinical experience drawn from Western populations (i.e., in North American, European and Australian). There may be features of depression in non-Western populations which are not captured in current diagnostic criteria or measurement tools, as well as criteria for depression that are not relevant in other regions. We investigated this possibility through a systematic review of qualitative studies of depression worldwide. Nine online databases were searched for records that used qualitative methods to study depression. Initial searches were conducted between August 2012 and December 2012; an updated search was repeated in June of 2015 to include relevant literature published between December 30, 2012 and May 30, 2015. No date limits were set for inclusion of articles. A total of 16,130 records were identified and 138 met full inclusion criteria. Included studies were published between 1976 and 2015. These 138 studies represented data on 170 different study populations (some reported on multiple samples) and 77 different nationalities/ethnicities. Variation in results by geographical region, gender, and study context were examined to determine the consistency of descriptions across populations. Fishers exact tests were used to compare frequencies of features across region, gender and context. Seven of the 15 features with the highest relative frequency form part of the DSM-5 diagnosis of Major Depressive Disorder (MDD). However, many of the other features with relatively high frequencies across the studies are associated features in the DSM, but are not prioritized as diagnostic criteria and therefore not included in standard instruments. The DSM-5 diagnostic criteria of problems with concentration and psychomotor agitation or slowing were infrequently mentioned. This research suggests that the DSM model and standard instruments currently based on the DSM may not adequately reflect the experience of depression at the worldwide or regional levels.

Adaptation and testing of psychosocial assessment instruments for cross-cultural use: an example from the Thailand Burma border

BackgroundThe purpose of this study was to develop valid and reliable instruments to assess priority psychosocial problems and functioning among adult survivors of systematic violence from Burma living in Thailand.MethodsThe process involved four steps: 1) instrument drafting and piloting; 2) reliability and validity testing; 3) instrument revision; and 4) retesting revised instrument.ResultsA total of N = 158 interviews were completed. Overall subscales showed good internal consistency (0.73-0.92) and satisfactory combined test-retest/inter rater reliability (0.63-0.84). Criterion validity, was not demonstrated for any scale. The alcohol and functioning scales underperformed and were revised (step 3) and retested (step 4). Upon retesting, the function scale showed good internal consistency reliability (0.91-0.92), and the alcohol scale showed acceptable internal consistency (0.79) and strong test-retest/inter-rater reliability (0.86-0.89).ConclusionsThis paper describes the importance and process of adaptation and testing, illustrated by the experiences and results for selected instruments in this population.

Development and cross-cultural testing of the International Depression Symptom Scale (IDSS): a measurement instrument designed to represent global presentations of depression

Background Self-report measurement instruments are commonly used to screen for mental health disorders in Low and Middle-Income Countries (LMIC). The Western origins of most depression instruments may constitute a bias when used globally. Western measures based on the DSM, do not fully capture the expression of depression globally. We developed a self-report scale design to address this limitation, the International Depression Symptom Scale-General version (IDSS-G), based on empirical evidence of the signs and symptoms of depression reported across cultures. This paper describes the rationale and process of its development and the results of an initial test among a non-Western population. Methods We evaluated internal consistency reliability, test–retest reliability and inter-rater reliability of the IDSS-G in a sample N = 147 male and female attendees of primary health clinics in Yangon, Myanmar. For criterion validity, IDSS-G scores were compared with diagnosis by local psychiatrists using the Structured Clinical Interview for DSM (SCID). Construct validity was evaluated by investigating associations between the IDSS-G and the Patient Health Questionnaire (PHQ), impaired function, and suicidal ideation. Results The IDSS-G showed high internal consistency reliability (α = 0.92), test–retest reliability (r = 0.87), and inter-rater reliability (ICC = 0.90). Strong correlations between the IDSS-G and PHQ-9, functioning, and suicidal ideation supported construct validity. Criterion validity was supported for use of the IDSS-G to identify people with a SCID diagnosed depressive disorder (major depression/dysthymia). The IDSS-G also demonstrated incremental validity by predicting functional impairment beyond that predicted by the PHQ-9. Results suggest that the IDSS-G accurately assesses depression in this population. Future testing in other populations will follow.

Measuring Hope Among Children Affected by Armed Conflict: Cross-Cultural Construct Validity of the Children's Hope Scale.

We investigated the cross-cultural construct validity of hope, a factor associated with mental health protection and promotion, using the Children’s Hope Scale (CHS). The sample (n = 1,057; 48% girls) included baseline data from three cluster-randomized controlled trials with children affected by armed conflict (n = 329 Burundi; n = 403 Indonesia; n = 325 Nepal). The confirmatory factor analysis in each country indicated good fit for the hypothesized two-factor model. Analysis by gender indicated that configural invariance was supported and that scalar invariance was demonstrated in Indonesia. However, metric and scalar invariance were not supported in Burundi and Nepal. In country comparisons, configural and metric invariance were met, but scalar invariance was not supported. Evidence from this study supports the use of the CHS within various sociocultural settings and across genders, but direct comparisons of CHS scores across groups should be done with caution. Rigorous evaluations of the measurement properties of mental health protective and promotive factors are necessary to inform both research and practice.

Local perceptions of the impact of group interpersonal psychotherapy in rural Uganda

Background. This study investigated local perceptions of changes stemming from a long-standing Group Interpersonal Psychotherapy (IPT-G) program for the treatment of depression in rural Uganda. The study was conducted in a low-income, severely HIV/AIDS-affected area where in 2001 the prevalence of depression was estimated at 21% among adults. Method. Data were collected using free-listing and key informant qualitative interviews. A convenience sample of 60 free-list respondents was selected from among IPT-G participants, their families, and other community members from 10 Ugandan villages. Twenty-two key informants and six IPT-G facilitators were also interviewed. Results. Content analysis yielded five primary categories of change in the community related to the IPT-G program: (1) improved school attendance for children; (2) improved productivity; (3) improved sanitation in communities; (4) greater cohesion among community members; and (5) reduced conflict in families. Community members and IPT-G facilitators suggested that as depression remitted, IPT-G participants became more hopeful, motivated and productive. Conclusion. Results suggest that providing treatment for depression in communities with high depression prevalence rates may lead to positive changes in a range of non-mental health outcomes.

Development process of an assessment tool for disruptive behavior problems in cross-cultural settings: the Disruptive Behavior International Scale – Nepal version (DBIS-N)

ABSTRACT Systematic processes are needed to develop valid measurement instruments for disruptive behavior disorders in cross-cultural settings. We employed a four-step process in Nepal to identify and select items for a culturally valid assessment instrument: (1) we extracted items from validated scales and local free-list interviews; (2) parents, teachers and peers (n = 30) rated the perceived relevance and importance of behavior problems; (3) highly rated items were piloted with children (n = 60) in Nepal; (4) we evaluated internal consistency of the final scale. We identified 49 symptoms from 11 scales, and 39 behavior problems from free-list interviews (n = 72). After dropping items for low ratings of relevance and severity and for poor item-test correlation, low frequency and/or poor acceptability in pilot testing, 16 items remained for the Disruptive Behavior International Scale – Nepali version (DBIS-N). The final scale had good internal consistency (α = 0.86). A 4-step systematic approach to scale development including local participation yielded an internally consistent scale that included culturally relevant behavior problems.

Local Perceptions of the Impact of Group Interpersonal Psychotherapy inRural Uganda

This study investigated local perceptions of changes stemming from a long-standing Group Interpersonal Psychotherapy (IPT-G) program for the treatment of depression in rural Uganda. The study was conducted in a lowincome, severely HIV/AIDS affected area where in 2001 the prevalence of depression was estimated at 21% among adults. Data were collected between May 10 and May 31, 2010, using free-listing and key informant qualitative interviewing techniques. A convenience sample of sixty free-list respondents was selected from among adults who had participated in IPT-G, their family members, and other community members, from 10 villages representing a range of sizes and geographical locations. Twenty-two key informants were also selected from these villages, based on their knowledge about changes reported by free-list respondents. Interviews were analyzed using content analysis and response frequency tallied. IPT-G facilitators were also interviewed about the reported changes. Free-list respondents identified 5 primary categories of change in the community related to the IPT-G program: 1) Improved school attendance for children; 2) Improved productivity; 3) Improved sanitation in communities; 4) Greater cohesion among community members; and 5) Reduced conflict in families. Key informant interviews with community members and IPT-G facilitators suggested that as depression remitted, IPT-G participants became more hopeful and motivated and resumed productive pursuits. Greater cohesion between group members and other affected community members led to increases in collaborative farming and building efforts, and to ongoing mutual emotional support and peer counseling. Changes reported in this study cannot uniquely be attributed to the IPT-G program as other development programs in the area, related to farming, sanitation, and education, may also have contributed. Nevertheless, results suggest that providing treatment for depression in communities where it is prevalent may lead to positive changes in a range of non-mental health areas that are perceived to be connected the depression services.

Testing the effectiveness and implementation of a brief version of the Common Elements Treatment Approach (CETA) in Ukraine: a study protocol for a randomized controlled trial

BackgroundMental illness is a major public health concern. Despite progress understanding which treatments work, a significant treatment gap remains. An ongoing concern is treatment length. Modular, flexible, transdiagnostic approaches have been offered as one solution to scalability challenges. The Common Elements Treatment Approach (CETA) is one such approach and offers the ability to treat a wide range of common mental health problems. CETA is supported by two randomized trials from low- and middle-income countries showing strong effectiveness and implementation outcomes.Methods/designThis trial evaluates the effectiveness and implementation of two versions of CETA using a non-inferiority design to test two primary hypotheses: (1) a brief five-session version of CETA (Brief CETA) will provide similar effectiveness for reducing the severity of common mental health problems such as depression, post-traumatic stress, impaired functioning, anxiety, and substance use problems compared with the standard 8–12-session version of CETA (Standard CETA); and (2) both Brief and Standard CETA will have superior impact on the outcomes compared to a wait-list control condition. For both hypotheses, the main effect will be assessed using longitudinal data and mixed-effects regression models over a 6-month period post baseline. A secondary aim includes exploration of implementation factors. Additional planned analyses will include exploration of: moderators of treatment impact by disorder severity and comorbidity; the impact of individual therapeutic components; and trends in symptom change between end of treatment and 6-month assessment for all participants.DiscussionThis trial is the first rigorous study comparing a standard-length (8–12 sessions) modular, flexible, transdiagnostic, cognitive-behavioral approach to a shortened version of the approach (five sessions). Brief CETA entails “front-loading” with elements that research suggests are strong mechanisms of change. The study design will allow us to draw conclusions about the effects of both Brief and Standard CETA as well as which elements are integral to their mechanisms of action, informing future implementation and fidelity efforts. The results from this trial will inform future dissemination, implementation and scale-up of CETA in Ukraine and contribute to our understanding of the effects of modular, flexible, transdiagnostic approaches in similar contexts.Trial registrationClinicalTrials.gov, ID: NCT03058302 (U.S. National Library of Medicine). Registered on 20 February 2017.